MEDICARE: FRED MEYER STORES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0002X	Clinic Pharmacy
3	332B00000X	Durable Medical Equipment & Medical Supplies
4	3336C0003X	Community/Retail Pharmacy	AK391	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1996601	OTHER	PK
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508802059
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRED MEYER STORES INC

Provider Business Mailing Address
First Line	:	PO BOX 842772
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02284-2772
Country	:	US
Telephone Number	:	513-762-1019
Fax Number	:	513-762-1092

Provider Business Practice Location Address
First Line	:	3755 AIRPORT WAY
Second Line	:
City	:	FAIRBANKS
State	:	AK
Zip	:	99709-4610
Country	:	US
Telephone Number	:	907-474-1433
Fax Number	:	907-474-1447

Authorized Official
Title or Position	:	MANAGER OF PHARMACY LICENSING
Name	:	ALLISON MUENNICH
Credential	:
Telephone Number	:	513-762-1019

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	10/14/2020

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Directions to “FRED MEYER STORES INC ” Practice Location

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